Management of Recurrent IgA Nephropathy in Transplanted Kidney

Initial Assessment and Monitoring

The Kidney International guidelines recommend screening for microhematuria at least once in the first month post-transplant to establish baseline, and monitoring microhematuria every 3 months during the first year, then annually thereafter 1, 2
Measure urine protein excretion once in the first month, every 3 months during the first year, and annually thereafter, as recommended by the Kidney International guidelines 1, 2
Obtain kidney allograft biopsy when there is new onset proteinuria, unexplained proteinuria >3.0 g/day, or persistent unexplained increase in serum creatinine, according to the Kidney International guidelines 1, 2

The Kidney International guidelines recommend initiating ACE inhibitor or ARB therapy for proteinuria >0.5 g/day, regardless of blood pressure status 1, 2, 3
Target blood pressure <130/80 mmHg if proteinuria <1 g/day, or <125/75 mmHg if proteinuria >1 g/day, as recommended by the Kidney International guidelines 3, 4
Uptitrate ACE inhibitor or ARB to maximum tolerated dose, aiming for proteinuria <1 g/day, according to the Kidney International guidelines 3, 4

Consider a 6-month course of corticosteroid therapy if proteinuria remains >0.75-1 g/day after at least 90 days of optimized supportive care and eGFR >50 ml/min/1.73 m², as recommended by the Kidney International guidelines 3, 4
Avoid or use extreme caution with corticosteroid therapy if eGFR <30 ml/min/1.73 m², according to the Kidney International guidelines 3

Treat with high-dose corticosteroids and cyclophosphamide, analogous to ANCA vasculitis treatment, as recommended by the Kidney International guidelines 4

Continue calcineurin inhibitor (CNI) at therapeutic levels to prevent rejection and minimize development of donor-specific antibodies, as recommended by the American Journal of Transplantation guidelines 5
Monitor CNI blood levels every other day during immediate post-operative period, with changes in medication, or with decline in kidney function, according to the Kidney International guidelines 6

Do not delay biopsy when there is unexplained proteinuria >3.0 g/day or persistent increase in creatinine, as early recurrence can occur as soon as 19 days post-transplant, according to the Kidney International guidelines 1, 2
Do not use immunosuppressive therapy in patients with eGFR <30 ml/min/1.73 m² unless there is crescentic IgAN with rapidly deteriorating function, as recommended by the Kidney International guidelines 3, 4
Do not initiate corticosteroids without first ensuring at least 90 days of optimized supportive care including maximally tolerated ACE inhibitor/ARB therapy, according to the Kidney International guidelines 3